203: Clause 23, page 38, line 2, at end insert-
“14Y1 Duty as to addiction to prescribed drugs
(1) Each clinical commissioning group shall have a duty to provide services to those suffering from addiction and withdrawal from prescribed drugs.
(2) In fulfilling this duty, clinical commissioning groups must co-operate with and take account of the work of non-governmental organisations.”
The Earl of Sandwich: My Lords, the Minister already knows that, in moving the amendment, I use the example of the dangers of prescribed drugs and the urgent need to commission services for those suffering from addiction and withdrawal. This amendment follows the interesting amendment of the noble Lord, Lord Rooker, on Monday. I am sorry that I could not support him in his attempt at a Division because he said a lot of interesting things, although I know that this has become an historic occasion. That amendment pointed to the advantages of building on the work of voluntary organisations, especially those in the vanguard of meeting a particular need, as they are in this case. I know that the Minister has given an answer, that the board and clinical commissioning may want to find work that will assist in the effective commissioning of services:
“For instance, the board may provide funding to voluntary organisations with particular expertise in the provision of support to people with rare specialist conditions”.-[Official Report, 28/11/2011; col. 119].
I have some experience of voluntary organisations, and I know that, on the whole, they provide a cost-effective service; the argument has already been well made in the debate. Using the example of prescribed drugs, research into current services has shown that, in a few cases, the NHS is already working alongside very frail NGOs. In some cases, the relationship is symbiotic. For example, in Belfast a very skilled NHS worker is leading the team. In Bristol, Oldham and Newcastle the PCTs are part-funding local services and providing care workers. However, in most areas of the UK PCTs are woefully unaware of the problem and the department is woefully unaware that the PCTs are unaware, and therefore no-one is able to provide the necessary training and meet the need. The noble Lord, Lord Warner, spoke earlier about the shortcomings of PCTs as commissioning groups in certain situations.
My first question is already answered: can the Minister assure me that he will do everything to support good practice in the voluntary sector for victims of prescribed drugs or for any other deserving category of patients? It would help if there was a duty to support NGOs in the Bill. I know that cannot be the case, and, as I say, the Minister has answered this.
Coming specifically to Amendment 203, I will briefly repeat my interest, because, as the Minister already knows, a relative of mine has been confined to his room for over a year in almost constant pain, unable to take part in everyday life or even in family life. I do not wish to ask for special pleading, because he is one of perhaps 1.5 million people who have taken sleeping pills or other benzodiazepines who are now at risk from drug addiction which in some cases is worse than illegal drug addiction. Most of this is at the hands of doctors. As I said at Second Reading, the NHS has created a problem and it is up to the NHS to solve it.
My research tells me that the Government are not solving it. They are confusing illegal with legal drugs and they are making polite noises about what they might do, but they are not doing it. They are making claims at a high level about services which are clearly not being provided at a lower level. While the voluntary sector is being forced to act on its own, the Government show little sign of supporting it and in the present climate are likely to resist anything new.
My amendment is about the CCGs commissioning services themselves. I know that we are going through a period of change and it is very hard to see what is now a PCT or an emerging CCG. I do know that a service confronting benzo-addiction withdrawal is not an easy service to set up. Voluntary activity so often stems from the experience of individuals who have had such experiences. Up and down the country, there are some people of high quality who have either been through the perils of addiction themselves or have been very close to someone who has been addicted. They are the people who can do the job. They are remarkable not only because they are able to apply their experience as carers and therapists without training, but because they have also had to teach themselves management, the ability to start an office, to raise funds, to advertise a service and most of all to balance time and money when there are so many other things to think about. It is like a health service in miniature. These are the people whom this Bill should support and to whom the CCGs should have a duty. I beg to move.
Baroness Masham of Ilton: My Lords, I support my noble friend’s amendments. Addiction to over-the-counter drugs is an important issue. It can cause suicide. It ruins families. People cannot work. It needs all our support and I hope that the Minister will do something about this.
Lord Alderdice: My Lords, I support the noble Earl. He initiated a debate on this question some time ago. As I said at the time, one has to be careful. There are many patients who benefit considerably from some of these medications, when they are given responsibly
and monitored responsibly, but that does not always happen. One has to take this particularly seriously because, while those with alcohol and drug addiction often come to the health service for treatment-although perhaps they should come more often-this kind of addiction to prescribed drugs is effectively an iatrogenic disorder. Patients have come to have these medications, and they are not all over-the-counter medications. They are available properly only through doctors, so doctors and the health service have to take a particular responsibility. In that regard, I support the noble Earl in his concerns and I hope my noble friend the Minister will be able to give some reassurance that this is regarded seriously as an iatrogenic disorder that the health service is in some cases responsible for bringing into play through absence of proper monitoring and, in some cases, errant prescribing.
However, there is a second component, which is the involvement of NGOs and charities in treatment. When I was a young psychiatrist, I was very interested in alcohol and drug addiction and I worked in a unit. We did not have a specialised unit in Northern Ireland at that time to deal with drug addiction. I looked around in Ireland, North and South, and on this side of the water to find a service that would work. I found a voluntary organisation for addicts. I had myself admitted and went through the whole process as though I was an addict, removing myself from any contact with family and all my worldly goods, as it were, engaging in all the groups and the responsibilities that people undertook, the therapy sessions and so on. It was a very important experience for me because, like some other things that I did, it helped me to see things from the point of view of the patient and the kind of things that we were expecting patients to undertake.
However, I was doing it not only for my own interest, but to try to see what services would be possible in Northern Ireland. It became clear to me that, for all sorts of reasons, it was extremely difficult-well nigh impossible-to implement a service of that kind within the NHS, because we put all sorts of restrictions on the NHS. For example, one of the things that was very important was to go and do the washing and the cooking and be involved together in those kinds of things. If you tried to do that in the NHS, you immediately ran into all sorts of regulations, which we frequently discuss in a place like this. So it is not always that easy to do.
In a more general sense, sometimes charities and voluntary organisations can bring special things to services that it is very difficult to provide in the context of the NHS. Some of these are experimental and we should wait to see whether they are successful before the NHS takes them on board. That is very appropriate, but the burden of my plea in support of what the noble Earl says is that we should try to ensure that the contribution that is made by charities, particularly smaller charities, and voluntary organisations, which can experiment in these ways, continues to be valued. I have received a number of reports of some of the smaller charitable organisations, in the current climate-not after changes in legislation-finding it increasingly difficult to survive, because they only provide limited services. We have to take this seriously. I do not necessarily say that it has to go in the Bill, but even at
this late stage in the evening, the noble Earl deserves credit for raising this question, and I hope my noble friend can give some comfort on it.
Baroness Finlay of Llandaff: My Lords, I also support my noble friend Lord Sandwich on this terribly important topic. It links back to standards of primary care, which we have spoken about earlier this evening. I know that it is very late, but I hope that the Minister might take this away and consider it in terms of the standards of monitoring of primary and secondary care-as has been said, this is an iatrogenic disease for many people-and the importance that the third sector can play and fill a major gap that is not filled by any services that are formally commissioned. Without the third sector, these people will end up becoming ever-more needing of NHS services, but sadly they often get services that are not appropriate to their needs.
12.15 am
Baroness Hollins: My Lords, may I briefly speak in support of the amendment? I suggest that the duty to provide services to those suffering from addiction and withdrawal should also be a duty to ensure prevention of inappropriate prescription, which I think was implicit in what the noble Earl was saying. There are some very good NICE guidelines available. That refers back to an amendment of my noble friend Lady Finlay. It is important that commissioning groups require clinicians to take note of NICE guidelines, which might assist in preventing this kind of problem developing in the future.
Baroness Thornton: My Lords, I was very pleased to put my name to the amendment tabled by the noble Earl, Lord Sandwich. He and I have been discussing this for several years from various vantage points of my own, as a Minister and then supporting him in debates in the House. In a way, we lose sight of patients with conditions when we discuss this Bill. We talk about the theories of the clinical commissioning groups and how the relationships will work, the coterminosity of things and all of that, but at the end of the day it is about people who are ill, who have conditions or who are in very grave need of support. That is this group of people-those who have been prescribed drugs in a perfectly normal way by doctors and who then become addicted to them.
Several things happen here, which the noble Earl has very eloquently described. One of them is that the NHS seems to find it difficult to distinguish between the addiction of these people and drug addiction for illegal substances. That means that the treatment that is offered is often inappropriate.
In a way, this amendment is a test of the efficacy of the Bill. Can this new architecture deal with the problem that is being posed by this group of patients? In a way, I am looking for an answer from the Minister to address that. There is no question that some small progress has been made in support of voluntary organisations and in a few parts of the National Health Service through PCTs, which are of course being abolished, to address this issue, but it is not sufficient. I am worried that that progress is in jeopardy in the transition.
How will the transition ensure that what already exists is supported? This particular issue is a special and important one. It is not a huge issue in the framework of billions of pounds being spent by the NHS, but it is very important for those patients for whom it matters and for those in the future. So who will have responsibility for it? At what level will it be addressed? And how will the transition protect what exists at the moment?
Baroness Williams of Crosby: My Lords, the point raised by the noble Earl, Lord Sandwich, who has worked very closely in this field, should disturb all of us. It is a very late hour and I do not wish to detain the Committee any longer, except to say that one of the parts of the answer to this problem could be a much closer involvement of pharmacists in the whole issue of the drug regulation of individual patients. I know that my noble friend Lord Clement-Jones has raised before the question of how far qualified pharmacists can be brought more closely into very integrated working with CCGs. I simply suggest that this may be one of the ways to limit the terrible plight that the noble Earl, Lord Sandwich, was talking about-an individual pharmacist related directly to somebody who was closely dependent on a drug regime and the misuse of that drug regime in a way that leads to addiction.
Earl Howe: My Lords, I add my thanks to the noble Earl for his continued commitment to highlighting the needs of those suffering from addiction to prescribed drugs. It is one of the virtues of our House that it allows scope for noble Lords to highlight these issues in this kind of context. I am the first to recognise the pain and the plight of those whose lives have often been seriously damaged by such addiction, not to mention the damage done to families.
There are clear national guidelines for the usage of and withdrawal from prescribed drugs such as benzodiazepines, and GPs, pharmacists and specialist prescribers have those guidelines, but we know that what the noble Earl said is correct. There is access to support and treatment services for addiction to medicines in most local areas but some local areas are woefully short of such services. My department has commissioned evidence-gathering reports looking at the problem of addiction to prescription and over-the-counter medicines. We published a report on that in May which found that support is provided from a variety of services across primary care, community care and the voluntary sector. However, it also found such patchiness of provision.
I am sorry that the noble Earl said that he felt the Government showed little sign of supporting this group of patients or indeed taking the cause seriously. The national drugs strategy sets out an ambition to tackle all drugs of dependence, including dependence on prescription and over-the-counter medicines. My honourable friend the Minister for Public Health, Anne Milton, convened a round-table meeting of experts to discuss the future action required to prevent addiction to medicines and to improve support for people who develop problems. It included consideration of specific actions to support the commissioning services to respond to addiction to medicines, and a draft note of the
actions agreed at the meeting has been published. We will be convening that round-table meeting in four to six months to review the progress against the action points. I hope that the noble Earl will accept that this is an indication not only of good faith on the part of the Government but of our appreciation that this is a problem that we have to tackle.
We believe that local bodies, with their greater knowledge and understanding of local health needs, are best placed to assess the needs for services in general. That includes rehabilitation and support services. Under the arrangements set out in Healthy Lives, Healthy People, local public health bodies will be responsible for the commissioning of services in line with local need to support people recovering from dependence. This will provide local areas with an opportunity to better integrate the commissioning of drug and alcohol intervention and recovery services. Services will be contracted from a wide range of providers including the voluntary and community sectors.
We think that local areas have a wealth of data at their disposal and the ability to consider this group of people within their local commissioning plans. The noble Earl, both implicitly and explicitly, cast doubt on the ability of local health bodies to tackle this problem. I have to concede that in many areas, or at least in some, the local structures have not been fit for purpose, but I highlight my belief that those local structures are being immensely strengthened by the arrangements that we are putting in place. Here I have in mind the health and well-being boards, which will be a local hub in which the health needs of an area and the priorities for healthcare can be defined and built in to the joint health and well-being strategies on which commissioning decisions should be based. The whole idea of that is that no group should fall through the cracks. If there is a need for a service, it should be identified through that process.
We do think that the outcomes framework, which does not appear in this Bill but overarches everything that we are doing, will expose poor practice. It will expose those groups of the population that are not being well served, and the commissioners will be called to account for their actions or lack of actions. So I cannot promise jam tomorrow, but I do, I hope, hold out the prospect of significant improvement in this area. I would just emphasise to the noble Earl that, in the mean time, the Government are not going to take their foot off the accelerator. We do intend that his concerns should be addressed, and I hope that what I have said is of some help and comfort to him.
The Earl of Sandwich: Well, I certainly am not going to pick a quarrel with the Minister after midnight. I do not accept everything that he said. I do not think that I have convinced him, but at the same time I have heard some very encouraging sounds, and he is quite right that I have followed what the Minister’s personal interest has produced so far, because that is important. His colleague, Anne Milton, is certainly seized of the problem. The question is: where do we go from here? I certainly will not prolong the discussion now, but I am grateful to have had the opportunity to raise it and thank everybody who took part in the short debate. I beg leave to withdraw the amendment.